ST. JOHN’S, N.L. — A review of Newfoundland and Labrador’s chief medical examiner’s office has found that the loss of a key piece of evidence in a murder investigation — a baby’s brain — was a “complex error” triggered by “systemic weaknesses” that left the organization vulnerable.

Dr. Matthew Bowes, the chief medical examiner for Nova Scotia, carried out the review and found “important deficiencies” at the Newfoundland office tasked with investigating the suspicious death of a four-month-old baby in November 2013.

In the review released Friday, Bowes said the infrastructure, equipment, information management and staffing levels at the chief medical examiner’s office are inadequate.

“The physical infrastructure of the office is inadequate for the current and future needs of the office,” he said, adding that there is an “immediate need for a digital information management system.”

“The professional staff is vulnerable to prolonged disruption, and succession planning needs to begin immediately,” Bowes said. “The administrative staff are dedicated but may be too few in number, even after the nurse investigators are hired.”

He said systemic weaknesses at the office include outdated record-keeping practices, a lack of formal policies and procedures, understaffing and a blurring of the lines between the hospital and chief medical examiner’s office.

Bowes said these deficiencies made the organization vulnerable and left “so little objective evidence” that he could not confirm the fate of the baby’s brain and dura, a membrane that surrounds the brain and spinal cord.

A second-degree murder charge against a Labrador man in the death of his infant son was withdrawn in 2015 after the boy’s brain was lost.

The review made several recommendations to improve the chief medical examiner’s office, including improving record keeping, better facilities and more staff.

However, it’s unclear whether the Newfoundland government will implement all the recommendations.

Justice Minister Andrew Parsons said in a statement that the report will be “valuable as we work to ensure the office of the chief medical examiner is operating effectively.”

He said the office is a “crucial part of the justice system in the province and it is imperative the office has the tools needed to properly operate.”